THE NEW YORK TIMES, TUESDAY, DECEMBER 1, 2020 N D7WHILE A RAGING PANDEMICcontinues to
force shutdowns and slowdowns, another
major risk to human health is not taking a
sabbatical: cancer.
In the early months of the pandemic, mil-
lions of people heeded warnings and fears
about contracting the coronavirus and
avoided, or couldn’t even get, in-person
medical visits and cancer screenings, allow-
ing newly developed cancers to escape de-
tection and perhaps progress unimpeded.
During this time, there was a steep de-
cline in screenings for cancer, as well as a
reluctance of patients with cancer to par-
ticipate in clinical trials for cancer treat-
ments. Many mammography centers, der-
matology offices and other venues for can-
cer screenings remained closed for months,
and routine colonoscopies, which should be
done in hospitals or surgical centers, were
actively discouraged to minimize strain on
medical personnel and equipment and re-
duce the risk of contagion.
Still, Dr. Norman E. Sharpless, director of
the National Cancer Institute, warned in
June that missed routine screenings could
lead to 10,000 or more excess deaths from
breast and colorectal cancers within the
next decade.
Cancers cannot be treated unless they’re
detected, and a review of 34 studies pub-
lished in October in the BMJ reported that
for every four-week delay in cancer detec-
tion and treatment, the risk of death from
cancer rises nearly 10 percent, on average.
The study found increased mortality follow-
ing delays in treatment for 13 of 17 cancer
types. Following a four-week delay in
surgery for breast cancer, the death rate in-
creased by 8 percent; for colorectal cancer,
it rose 6 percent.
The hazard of delayed screenings is
greatest for people with known risk factors
for cancer: a family or personal history of
the disease, a previous abnormal Pap
smear, prior findings of polyps in the colon
or rectum, or, in the case of breast and cer-
tain other cancers, having genetic muta-
tions that seriously increase cancer risk.
Most screening facilities have since put
safety procedures in place that greatly re-
duce the chance of contracting the corona-
virus. Although I had postponed my annual
mammogram for four months, when I did
go in September I was impressed with how
well the facility was run — no one else in the
waiting room, everyone masked and hand
sanitizer everywhere.
Dr. Barry P. Sleckman, director of the
O’Neal Comprehensive Cancer Center at
the University of Alabama at Birmingham,
said in an interview, “When it comes to
screening for cancer, people should balance
the possibility of contracting the virus with
their potential cancer risk. People should do
everything possible to keep up with cancer
screenings.”
However, Dr. Sleckman added, “If a wom-
an is young and has no family history of
breast cancer, she can probably wait six
months for her next screening mammo-
gram.” He also suggested discussing the
matter with one’s personal physician, who
probably also knows the safest facilities for
screening.
If someone is found to have cancer, he em-
phasized, “There’s no reason to delay treat-
ment. If a woman has cancer in a breast, it
needs to be removed, and she should go to a
hospital where she can be treated safely.”
Dr. David E. Cohn, chief medical officer atthe Ohio State University Comprehensive
Cancer Center, said that in the early months
of the pandemic, “we experienced a signifi-
cant decline in new patients.”
“Even some patients with symptoms
were afraid to come in or couldn’t even see
their doctors because the offices were
closed,” Dr. Cohn continued. “This could re-
sult in a delayed diagnosis, more complex
care and potentially a worse outcome.”
But he said his center had since returned
to baseline, suggesting that, despite the
fall’s surge in Covid-19 cases, few cancer pa-
tients now remain undiagnosed and un-
treated.
“We made creative adaptations to Covid”
to maximize patient safety, Dr. Cohn said in
an interview. “For certain cancers, instead
of doing surgery upfront, we treated pa-
tients with radiation and chemotherapy
first, then did surgery later” when there
was less stress on hospital facilities and per-
sonnel and patients could be better pro-
tected against the virus.
Dr. Cohn said that certain kinds of sup-
portive care could be delivered remotely tocancer patients and their families — even
genetic counseling, if a DNA sample is sent
in. However, he added, “the majority of can-
cer treatment has to be administered in per-
son, and surveillance of cancer patients is
best done in face-to-face visits.”
Now with the virus surging around the
country, many medical centers may be
forced to again limit elective procedures,
those not deemed urgent. But, Dr. Sleckman
said: “Cancer treatment is not elective. It’s
urgent and should not be delayed.”
Learning that one has cancer, even when
it is early and potentially highly curable, is
likely to strain a person’s ability to cope with
adversity, all the more so when the diagno-
sis occurs in the midst of an already highly
stressful and frightening pandemic.
Kristen Carpenter, a psychologist at the
Ohio cancer center, said the constraints of
the pandemic were “using up a lot of peo-
ple’s reserve for dealing with adversity.”
Adding a cancer diagnosis on top of that
may initially cause people to fear they can’t
deal with it, she said in an interview.
But it is nearly always possible to make
more room in a person’s “bucket of reserve,”
Dr. Carpenter said, for example, by identify-
ing things that bring joy or a sense of ac-
complishment. Though the pandemic may
preclude great joys, she said, “people can
create a constellation of smaller joys,” like
reading a book or taking a walk. “A little
goes a long way to relieve the stresses of the
day and build up the reserve needed to help
you deal with the cancer,” she added.
Noting that many people have found new
ways to interact with others during the pan-
demic, “this is all the more important to do
in the face of cancer,” Dr. Carpenter said.
“Remember, you’re not just your cancer.
You’re a whole person experiencing some-
thing. Take time to identify your needs and
tell people what they are — don’t wait for
them to ask.”
This advice is especially critical to cancer
patients whose disease or treatment has
compromised their immunity, leaving them
especially vulnerable to infection by the co-
ronavirus. A friend with chronic lymphoma
who must avoid in-person contact with her
five young grandchildren visits them
through a glass door and observes their de-
light in retrieving the little treats she leaves
for them on her porch.
Think, too, of how you’ve faced difficul-
ties in the past, “how you’ve adapted to
things you previously believed to be un-
imaginably difficult,” Dr. Carpenter sug-
gested. Resiliency in the face of cancer dur-
ing Covid need not have a limit, she said.No Breaks for Cancer Amid a Pandemic
Danger of delayed screenings
is greatest for people with
known risk factors.
GRACIA LAM‘Cancer treatment is not
elective. It’s urgent and
should not be delayed.’
DR. BARRY P. SLECKMAN
UNIVERSITY OF ALABAMA
AT BIRMINGHAMPERSONAL HEALTH JANE E. BRODYWe l l
THE PRESIDENT-ELECT,Joseph R. Biden Jr.,
has no shortage of ideas about how to trans-
form caregiving. One striking feature of his
team’s plan: It does not address elder care
separately from child care, or divide plans
to support family caregivers from those for
paid caregivers. Rather, it takes on Medic-
aid benefits for older and disabled adults,
preschool for toddlers and better jobs for
home care workers, all in one ambitious,
$775 billion-over-a-decade package.
“It approaches the care economy in a ho-
listic way, across the age spectrum,” said Ai-
jen Poo, executive director of the National
Domestic Workers Alliance, which has long
pushed many of those measures. “It’s a big
breakthrough.”
The same families who need child care in
order to stay employed are often responsi-
ble for aging relatives, she pointed out, and
many work as paid caregivers themselves.
Elements of the Biden plan, announced
last summer, will sound familiar. The cam-
paign for paid family leave, whether for
childbirth or for care of older parents, goes
back decades. So does the ongoing effort to
rebalance Medicaid, making it more able to
cover caregiving at home, where most older
adults hope to stay, rather than in the nurs-
ing homes they dread.
But the coronavirus pandemic and the ac-
companying economic crisis have spot-
lighted the halting, fragmented way the
United States approaches these issues,
compared with other industrialized democ-
racies.
Advocates see this emergency as ruinous
for families and workers, and as an opportu-
nity to tackle long-deferred needs. Policies
like converting the anemic federal Family
and Medical Leave Act, which mandates
only unpaid leave, into 12 weeks of paid
leave, as Mr. Biden has proposed, could help
propel the nation’s labor force back to work.
“Working adults are buckling under the
pressure of addressing child care on one
hand and care for elders on the others,” Ms.
Poo said. “Women are leaving the labor
market because they have impossible
choices.”
Fatima Goss Graves, president and chief
executive of the National Women’s Law
Center, said: “What was important to peo-
ple became urgent. There are periods
where acceleration feels possible, and this
is one of them.”
Despite its integrated approach, the Bi-
den plan does call for certain programs
most likely to benefit older people and their
caregivers. For example, it proposes a tax
credit for as much as $5,000 to reimburse
families for expenses associated with un-
paid caregiving.
“It helps the people in the middle, stuck
between Medicaid” — which primarily
benefits the very low-income — “and those
with the resources to pay for long-term
care,” said C. Grace Whiting, president and
chief executive of the National Alliance for
Caregiving.
An AARP survey last year found that
families spent about $7,400 out of pocket an-
nually, and close to $13,000 if the caregivers
lived an hour or more away from the rela-
tives they helped. In another AARP study,
about one-quarter of family caregivers re-
ported taking on more debt and depleting
their savings.
Ms. Whiting ticked off some costs the
credit might cover: “Household expenses.
Paid help. Home modifications. Remote de-
vices to monitor safety. Equipment like
hearing aids. Medical expenses not covered
by other payers.” The Biden plan would also
give family members Social Security cred-
its for the time they spend out of the work
force caring for loved ones.
An Urban Institute analysis found that
this change would most benefit lower-in-
come workers, by crediting them with earn-
ings equal to half the average national
monthly wage, in addition to their other
earnings, for every month in which they
provided 80 or more hours of unpaid care.
One of the Biden plan’s most far-reaching
components for seniors concerns Medicaid.
This state and federal program underwrites
most long-term care, but it has historically
spent more on nursing homes than on so-
called home and community-based serv-
ices. About 800,000 people linger on state
waiting lists for home care, sometimes for
years, the Biden team has said.
The shift to home services, which now
represents more than half of Medicaid
spending on long-term care, has been
“vastly inadequate,” Ms. Poo said. “It’s still
not mandatory for states to offer home and
community-based services as an option.”
The Biden plan vows to eliminate the wait
list, then enhance federal contributions to
allow states to develop more community al-
ternatives, which are generally less expen-
sive than nursing home care.
Finally, it tackles the issues that have led
to persistent churn in the mostly female
work force that provides elder care and
child care, including low wages, lack of
benefits like health insurance and sick
leave, and the need for further training.That effort, the plan notes, will support
unionization and collective bargaining.
“The solution cannot be caregivers at pov-
erty levels with unfair working conditions,”
Ms. Goss Graves said.
The Biden team asserts that the nation
can pay the tab for this vast undertaking
over 10 years, by rolling back tax breaks for
real estate investors with incomes over
$400,000 and increasing tax compliance for
other high earners.
It also argues that the plan will create
three million new caregiving and education
jobs, and increase employment by five mil-
lion by allowing unpaid caregivers to re-en-
ter the work force.
Debate is certain to ensue over the price
tag nonetheless, given a fragile economy,
and over whether these plans represent the
best solutions to the nation’s child care and
elder care needs.
As Ms. Whiting pointed out, “the tax cred-
it puts money back in caregivers’ pockets,
improving their well-being.” But it won’t
benefit lower income families who don’t pay
much income tax, or any, unless it’s made
“refundable,” so that a caregiver could re-
ceive a reimbursement check for more than
she paid the I.R.S.
Social Security credits would most likely
have greater impact, said Richard Johnson,
an economist who directs the Urban Insti-
tute Program on Retirement Policy. One
drawback, however, is that “it doesn’t help
caregivers until they begin collecting Social
Security,” he said. “The tax credit could pro-
vide immediate help.”
Of course, the political odds of realizing
all these ideas, or any of them, remain
highly uncertain, even if the Senate ac-
quires a slender Democratic majority. “Thequestion will be ‘Do we have the political
will to make it happen?’ ” Ms. Whiting said.
Some Medicaid changes will also require
agreement from state governments.
The plan does not delve into details about
how the administration would carry out all
these policies, and the Biden transition
team did not make a policy adviser avail-
able to discuss the president-elect’s goals
and strategies. But some aspects of the plan
— efforts to pass a caregiver tax credit, for
instance — have previously drawn congres-
sional sponsors from both parties.
“There’s growing recognition of the es-
sential help provided by family caregivers,
and an emerging consensus among both
Democrats and Republicans that they need
more support,” Dr. Johnson said. “So the
time might be right to enact meaningful fed-
eral legislation.”
Supporters of the plan see Mr. Biden as a
president with an unusually personal un-
derstanding of caregiving. He has been a
single father and a caregiver both to injured
children and to a grown son with terminal
cancer. In announcing his caregiving plan,
he also mentioned caring for his parents,
when they were hospice patients, in his
home.
Vice President-elect Kamala Harris was
the principal sponsor of the National Do-
mestic Workers Bill of Rights last year.
“They’re the right people to lead the conver-
sation,” Ms. Whiting said.
But as veterans of the effort to promote a
more expansive federal approach to care-
giving, advocates like Ms. Goss Graves
have also developed a well-honed realism.
“Things don’t happen on their own,” she
said. “I’d feel hopeful, but I’d also be prepar-
ing to get to work.”Biden’s Plan Takes
A Holistic Approach
To Support Caregivers
The incoming administration
aims to help those who look
after the young and the old.
President-elect Joseph R. Biden
Jr.’s program to improve
caregiving would be paid for in
part by rolling back tax breaks
for real estate investors with
incomes over $400,000.RUTH FREMSON/THE NEW YORK TIMES‘What was important
to people became
urgent. There are
periods where
acceleration feels
possible, and this is
one of them.’
FATIMA GOSS GRAVES
NATIONAL WOMEN’S
LAW CENTERTHE NEW OLD AGE PAULA SPAN